“What is the Cost of Failure?” and Other Questions Your Team Should Ask

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“What is the cost of failure?”

This is the question Shannon Welch, MPH, sometimes asks quality improvement (QI) teams. It is her way of encouraging them — when they are excited about a change and want to jump into full-scale implementation — to slow down and consider their plans thoughtfully.

“If the cost of failure is high,” Welch cautions teams, "you want to start with a small test of change."

Welch, an Institute for Healthcare Improvement (IHI) Senior Director and Improvement Advisor, understands why QI teams may be in a hurry to make their ideas for improvement standard practice across their system. They see problems, and they want to fix them. It may seem counterintuitive not to forge ahead to make changes when the current system may be leading to harm, inefficiencies, inequities, or wasting time or money.

While not wanting to dampen their enthusiasm, Welch urges teams to consider how much good will or support they might lose if their ideas do not take hold. The hard truth is that failure may have nothing to do with an idea’s merits. A lack of leadership support or misunderstandings about the change are only two of many factors that may hinder an idea’s success. Conducting small tests of change can bring issues like these to light so a team can address them.

Learn to Coach Your Team to Success

Welch shared the story of an improvement team that designed a new curriculum. After finishing its development, they wanted to immediately implement it. Instead, she and her team coached them to “break their curriculum into bite-sized chunks, and test pieces with small groups of individuals to learn whether the content was clear and resonant” with others. Though it initially may have seemed overly cautious, this approach led to success because the team learned from each of their tests. “They were [eventually] able to build a fantastic curriculum that is now being spread in states across the US,” Welch recounted.

Counseling teams to conduct small tests of change is one of many pieces of advice Welch shares when working with improvement teams. In a recent IHI interview, she recommended that QI teams ask themselves key questions to overcome a range of challenges:

• Are you letting “perfect” be the enemy of “good”? Newly formed improvement teams often hesitate to jump in and start learning by doing. As Welch noted, “Sometimes there’s a hesitancy, a desire to have all of the data you need, and an urge to plan every last detail.” One of the reasons to test small changes via Plan-Do-Study-Act (PDSA) cycles, rather than “going big” on full implementation, is precisely to overcome this kind of hesitation. Instead, she advised, the sooner you start testing, the sooner you start learning.
• Are you centering equity in your improvement work? Centering equity in improvement projects involves stratifying data by race, ethnicity, language, sexual orientation, and gender identity so we can better understand what is happening for different populations and ensure equitable outcomes. “If we don't stratify our data,” Welch cautioned, “the numbers will mask the inequities and disparities that we know are there but are not necessarily visible.”
• Are you centering equity on your improvement team? Centering equity also means building a culture of equity within your improvement team by recognizing that no individual has all the answers and actively seeking input from diverse perspectives. It is important to create a psychologically safe and inclusive space where everyone feels comfortable sharing their ideas and challenging the status quo. To quote W. Edwards Deming, “Every system is perfectly designed to get the results it gets.” This includes our own QI teams. Welch noted, “If we are going to achieve equity, we need to have the courage to look within ourselves, and within our own teams, to see how we can improve our systems and how we are providing care.”
• Do you have a defined theory of change? Some improvement teams may use logic models while others use driver diagrams. The point is to have a theory of change. As Welch explained, “As we go into any improvement work, it is important to be clear on what we believe will lead to the outcome we want to see.” With a defined theory of change, teams can then test and learn to see if their theory holds true or where they might need to make adjustments.

Welch stated that people often assume QI is complicated until they understand that we all engage in improvement throughout our lives. “People sometimes think using improvement methods may slow us down when we want to make changes,” she observed. “Actually, improvement comes naturally to us because wanting to improve is part of who we are as human beings.”

Photo by Cindy Tang | Unsplash

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